5 Things to Know When Transitioning to an ENFit^® Connector System

What Do We Need to Know About the ENFit Connector System?

Enteral system connector changes and the new design standard for the enteral feeding system (ENFit) is most likely being evaluated by hospitals and healthcare systems as I write this, as it’s a best practice to regularly re-evaluate practices to continuously improve upon them. For this reason, I would like to share five key points that you will need to know to best support your hospital conversion to the ENFit connector design standard. This is not going to be a formal checklist or structured protocol. Instead, this will be a short and informative list detailing the top five most important points that you really need to know in order to navigate the conversion to the new ENFit connector design standard for enteral feeding. It is my goal to provide insights that will be helpful to get you through the process with the least amount of headaches and as few new gray hairs as possible. If you prefer more structured details and/or formal checklists, I will provide those at the end.

Many hospitals are evaluating enteral practice and their current enteral system connectors. Improving enteral feeding safety has long been identified as a safety issue by the Joint Commission. The primary reason this has escalated to a level of urgency is related to recent notifications by the Global Enteral Design Supplier Association (GEDSA) announcing the ENFit connector conversion scheduled for the U.S.

GEDSA supports the use and global transition to the ISO Standard 80369-3 enteral design connection, also known as the ENFit connector, and phasing out legacy enteral connectors. The recent communication provides a robust timeline of mid-year 2021 for legacy products and early next year, January 2022, for transition connectors. I’d like to add that not all supplies have committed to the above timeline and Medela, as an enteral supplier, is not committed to these dates and has no plans as of this publication date to discontinue legacy products.

You may be asking, why would I be willing to share this information? I was registered nurse and nurse manager in the hospital setting for more than 20 years prior to taking my current position. Also, in my current role, I have had an opportunity to observe and support hospital leadership as they take on this practice change. In a nutshell, I have been in a very similar situation and I would have appreciated some genuine direction. Here’s my best advice:

1. Gather the Teams!

As I am sure you already know, whenever a change in practice of significant magnitude is being made, it is going to take a team. Truth be told, it will take a committee of multi-disciplinary team members from various departments in order to ensure every impact the transition may have on each of these departments. Changing to the ENFit connector will impact every unit in your hospital. It will be important to have a representative from every department and unit in your hospital, including inpatient and outpatient units. Clinical members from each department will need to map out their current feeding practices and evaluate current enteral products to understand how the ENFit connector will impact feeding practices.

ENFit connectors have a reverse gender locking connector that causes the male end to be on the feeding tube side of the connector. The connector or hub has threads or track that is surrounded by a collar for connectivity – this part of the ENFit connector creates challenges for both keeping the hub clean and delivery of oral medication.  If you work in a specialty unit, such as neonatal, pediatrics, or oncology, it will be imperative that you have a representative from your unit, a clinical lead, or educator involved – They should definitely have a seat at the table on this committee.

2. Vendor as a Partner

The vendor (often referred to as supplier) selected to provide your hospital with enteral ENFit products can be a huge asset or hindrance.  When considering suppliers, there are a few key points to consider. Of course, you will want to be sure they can provide ENFit products and what their plan is if there are supply challenges, such as an increase in usage, if products are out of stock, or something else. Will they have alternate products to offer if needed?

Oftentimes, vendors will say their products accommodate a broad patient range from adults to neonates. I would question if their products support the unique needs of “all” patient populations. Not all patient and departmental needs are created equal. For example, in the NICU, patients are not just smaller adults that use smaller-sized products; instead, it is important to have products that are designed for and take into consideration the unique needs of neonates. Premature infants require the use of a feeding tube for much longer periods of time than the adult population. There is not one vendor on the market today that has every ENFit product that will be needed to transition your entire hospital to ENFit. It is likely that your hospital supply chain and/or purchasing team chooses more than one vendor to support your hospital needs.

Another important point to keep in mind when selecting a supplier is to choose one that can be a partner aligned with YOUR goals. Choose a supplier that can be a resource when developing your transition plan. They should have extensive experience with converting large healthcare systems with enteral system connector changes. Can they provide insights and best practices to aid with overcoming inherent pitfalls related to the global design of ENFit connectors? Meet with the sales representatives, as they should be extremely knowledgeable about enteral products and the application-specific changes relating to ENFit. Ask if they have a clinical representative (RN, NNP, RD) as part of their core team that will be available to support and address any complex or unique practices to your facility that may come up during the planning or conversion. Do they provide training support for users on their product, and is it on-site training, providing teaching tools, and are they available outside normal business hours (for your evening/night shifts)?

3. Education and Training on the ENFit Connector

It is a best practice to think about this early in the process. In my experience, the transition is a lot smoother when the clinical team, especially the end user, has knowledge of this change well before it occurs.

• Educate all of the clinical staff on the reasons why the decision has been made to convert to an ENFit connector for enteral feeding to enhance patient safety.
• Educate on the differences between the oral and ENFit tip. Include nursing staff in the assessment of how this practice change will impact their practice and patient care.
• You may wish to develop a plan for keeping the ENFit hub clean.
• Evaluate how this change will impact oral medication preparation and delivery protocols. Include medication from pharmacy, and unit-stocked meds supplied in a cup application or crushed pills.
• Also, consider any additional changes that may need to be made on the unit, considering the ENFit global design syringe tip has a larger opening, female tip.

Following the evaluation of all practice or procedure changes, the clinical teams will need to be trained on these changes. Consider a variety of training tools and resources that may be available by your supplier (such as quick starts or YouTube videos) and adopt the most meaningful for your nursing staff. Implement training that supports effective learning by keeping in mind the specific needs of individual units, staffing, and work hours. If changes are being made to supply, stocking locations, or workflow, it will be essential to communicate them during the training.

4. Patient Transfers

Patients entering your hospital system may arrive with non-ENFit enteral product applications (such as gastrostomy tubes). Patients transferring to your hospital from another acute care facility or home will have the ENFit connector. A key component to include in your plan should be transition connectors. They will allow your center to provide immediate care for patients that do not have ENFit connectors. Keeping safe enteral practices in mind, it is a safer practice to use transition connectors that are for enteral/oral use only and are incompatible with lure lock IV connectors. There are transition connectors that fit this criteria as recommended by the ISMP – Dual Cap is a product that is available and satisfies this criteria.

5. Patient Discharges

Until enteral products with ENfit connectors are widely available and accessible for patients going home, it will be important to ensure patients have access to ENFit products at home. The continuation of care from hospital to home with ENFit products continues to be a work in progress, depending on availability with the community. How patients will be managed at home and access to ENFit products by pharmacies and DMEs continues to evolve. It will be important to evaluate the geography.

Additional Resources for You

As promised, here are some additional resources that will be helpful with your hospital transition to ENFit enteral system connectors:

• Global Enteral Device Supplier Association
• Enteral Connector (ENFit^®) Resources. StayConnected
• Transition Checklists: Download the right checklist for your team or organization
• ASPEN Safe Practices for Enteral Nutrition Therapy: Question 9.3 and 9.4 report on current methods to prevent enteral misconnections and best practices to systematically
• Managing the risk of tubing misconnections during the transition to new ISO connector (ENFit) standards

Notwithstanding all of the planning and preparation prior to the conversion, there may be an unexpected or unforeseen challenge that comes up. After considering the above 5 things and the additional resources provided, you should be able to anticipate this and your hospital healthcare team will be more than prepared to address these challenges and quickly pivot to improve practice. If you have identified practices or issues encountered during the transition or post-transition to ENfit connectors, I would be thrilled to learn and share with others as they also take on this journey.

References

1. The Joint Commission. Sentinel Alert Event: Issue number 53. Managing risk during transition to new ISO tubing connector standards sea_53_connectors_8_19_14_finalpdf.pdf (jointcommission.org)
2. Global Enteral Device Supplier Association (GEDSA). ENFit Connector Conversion Schedule. Microsoft Word - Microsoft Word - 200914_REVISED_ENFit^®_Connector_Conversion_Schedule_U.S._Canada_Legacy_Connector_Production Phase_Out_Dates .docx (stayconnected.org)200914_REVISED_ENFit^®_Connector_Conversion_Schedule_U.S._Canada_Legacy_Connector_Production Phase_Out_Dates .docx (stayconnected.org)
3. Acute Care ISMP Medication Safety Alert. Transition adapters for ENFit syringes can defeat the purpose of ENFit itself. September 2017. Retrieved from: Featured Articles | Institute For Safe Medication Practices (ismp.org)